Provider Demographics
NPI:1912968462
Name:HENRY, TRACY (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 2K
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-452-2200
Mailing Address - Fax:315-452-2204
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 2K
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2200
Practice Address - Fax:315-452-2204
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7845Medicare ID - Type UnspecifiedMEDICARE NUMBER